7, 9–11 Studies from sub-Saharan Africa suggested that asymptomatic parasitaemia in children in high-transmission settings could be as high AT13387 as 71% in under-five children12, and between 37% and 68% in children aged up to ten years of age.13, 14 A hospital-based study in Kenya in 1996 found that up to 45% of children admitted with respiratory signs (indicative of severe ARI) had malaria as the primary diagnosis.15 In Ghana and Kenya, the probability of fever that could be attributed to malaria was found to be as

high as 61% and 67% respectively.16, 17 Up to half of all mortality among African children aged 6 months to 5 years was considered to be due to malaria 18 and nearly 3% of disability adjusted life years was attributed to malaria mortality globally.19 With such high levels of malaria-related morbidity and mortality, it was considered neither cost-effective nor safe to routinely distinguish malaria from non-malaria cases, and restrict antimalarial drugs to only confirmed cases, particularly where the Pomalidomide mouse attempt to do so could lead to rapid clinical deterioration and possibly death. The evidence supported the use of fever as a proxy indicator of malaria in both clinical care and epidemiological surveys. 7, 20, 21 Availability of affordable, yet effective antimalarials

The availability of affordable, yet effective antimalarials such as chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) was another important justification for the presumptive approach. Both TCL were effective first-line antimalarial drugs in endemic countries in sub-Saharan Africa for many years. Being synthetic products, CQ and SP were cheap to produce and were affordable. They were also safe to use, including as chemoprophylaxis in pregnant women. Drug pressure exerted through their use in the presumptive treatment of uncomplicated malaria22 contributed to development of resistance. In 2004, Ghana joined many countries across sub-Saharan Africa in changing its

first-line drug for the treatment of uncomplicated malaria from chloroquine to artemisinin-based combination treatments. Reports of resistance and or prolonged parasite clearance associated with use of the artemisinins in Western Cambodia, and along the Thailand-Myanmar (Burma) border raise concern about the need to protect the ACTs from unwarranted use. 23–25 Lack of appropriate diagnostic tools The lack of easy-to-use, accurate and reliable malaria diagnostic tools was another important justification for adoption of the presumptive approach. 7, 26, 27 Blood smear microscopy using Giemsa stain techniques which had been the mainstay of parasitological confirmation of malaria for many years, was too elaborate, technical, and expensive to set-up and maintain in all primary care facilities and was time-consuming.